The Importance of Medical Documentation
Medical documentation is necessary to claims being paid quickly
In today’s healthcare world you need to develop the necessary organizational controls to develop successful processes and procedures in order to stay compliant and financially healthy. The key to excellent documentation is knowing what is required and what is not. Medical reimbursement comes only from what you have documented if something is not written down it did not happen. This documentation is also a crucial form of communication. The importance of writing complete, concise, dated and timed documentation cannot be stressed enough. It is not only how you are reimbursed, but legal protection and critical communication. In the event of a medical malpractice lawsuit the only tools you will have to work with is what has been recorded.
Accurate documentation begins with gathering patient information from the very first point of contact, and continually updating as the patient moves through the healthcare process. Using verification tools will enable you the insight to see how you will be paid for services, and which services and procedures will require further approval from their healthcare provider. Medical documentation is telling the patient story and applying the correct billable codes. Once services have been rendered it is the facilities responsibility to transcribe said services into billable charges. With clear and concise documentation, you can assign medical billing codes to the claim. These billable codes are the vehicle to revenue. They are inflexible and must be followed to maintain a healthy bottom line.
Understanding the importance of good documentation is crucial to all aspects of the medical record. Documentation is more than legal protection. Medical records are a vital form of communication, and the importance of accurate and dated communication cannot be reiterated enough.
Communicate the treatment plan
Good documentation promotes continuity of care through clear communication with all that are involved in patient care. This is a way to communicate your treatment plan to other providers for the patient. This level of communication ensures the highest quality of care.
It’s a legal document from the medical provider
A medical record is a legal record of services rendered by the medical provider. Once written it is permanent. In case of legal proceedings written documentation is called upon and reviewed to help support an argument either way. So again clear, concise documentation is crucial to every step of the process.
It’s a document of medical services for the insurer
Medical documentation tells insurance providers what they are paying you for. Each case is coded and translated into a cost for your practice. Thorough documentation of all medical issues and treatments is therefore critical to your bottom line.
How do I get paid by insurance?
Your documentation is a process of taking all that is written and identifying it as a diagnosis’s, medical tests, treatments, and procedures for medical insurance. This information is then transcribed into standardized codes. These codes are what are then used to bill government and commercial payers for reimbursement of services rendered.
Medical billers are the professionals in charge of processing patient data, which would include treatment records, medical plans, and all related insurance information. Medical billers work to ensure that you, the healthcare provider is accurately and efficiently paid for the services performed.
A full understanding of medical insurance, the claims process, the appeals process, and the impact on your revenue cycle gives the medical billing professional the necessary knowledge to maximize revenue performance. The financial health of your practice depends on the effectiveness and overall performance of the billing office.
Let’s take look at your revenue cycle. Revenue cycle management is an invaluable part of a successful healthcare organization. Without a trustworthy and efficient billing company, you would be losing out on thousands of dollars in payer reimbursements, patient payments, that your practice depends on.
Understanding and executing an outstanding revenue cycle is an integral component of success. We have all heard of location, location, location for successful real estate endeavors well for successful revenue cycle management it comes down to documentation, documentation, documentation.